1. Superficial muscles of the back:
Arranged in two layers:
First layer:
Trapezius
Latissimus dorsi
Second layer:
Levator scapulae
Rhomboideus major and minor

2. 1.Trapezius: Origin: Superior nuchal line of occipital bone
ligamentum nuchae
Spinous process and supraspinous ligaments of all thoracic vertebra

3. Insertion: Posterior border of the lateral one third of the clavicle
Medial border of acromion and upper lip of the crest of spine of scapula
Deltoid tubercle

4. Nerve supply: Spinal part of accessory nerve
Actions:
Upper and lower fibers – rotate the scapula
Upper fibers along with levator scapulae elevate the scapula
Middle fibres of trapezius and the rhomboids together retract the scapula
Nerve supply: Spinal part of accessory nerve

5. 2.Latissimus dorsi: Origin:
lower six thoracic spines and supraspinous ligaments
Spines and supraspinous ligaments of all lumbar and sacral vertebra
Outer lip of iliac crest

6. Insertion: Floor of intertubercular sulcus of humerus
Nerve supply: Thoracodorsal

7. Actions: Extension of shoulder joint
In combination with the pectoralis major it is powerfull adductor

8. 3.Levator scapulae: Origin: Insertion: Nerve supply:
Transverse process of upper four cervical vertebra
Insertion:
Dorsal aspect of vertebral border of scapula
Nerve supply:
Ventral rami of C3 and C4

9. Actions:
Elevates the scapula in combination with upper part of trapezius

10. 4.Rhomboideus major: Origin: Insertion:
Spinous process of T2 to T5
Insertion:
Dorsal aspect of medial border of scapula
Nerve supply: Dorsal scapular nerve

11. 5.Rhomboideus minor: Origin: Nerve supply: Dorsal scapular nerve
Ligamentum nuchae
Spinous process of C7 and T1
Nerve supply: Dorsal scapular nerve

12. Actions: Combined with middle fibres of tapezius retract the scapula
With levator scapula depress the shoulder

13. THE BREAST

14. THE BREAST / MAMMARY GLAND:
It is present in both sexes
It is a modified sweat gland

15. Situation: Extent: Vertical: Horizontal:1
It lies in the superficial fascia 2 3
Extent: 4 5
Vertical:
Second to sixth rib
Horizontal:
Later border of sternum to the mid axillary line 6
Axillary tail of spence

16. Relations: Mammary bed Retro-mammary space Pectoral fascia
Pectoralis major muscle
Serratus anterior muscle
External oblique muscle
Mammary bed
Retro-mammary space
External oblique
Serratus anaterior

17. Features in the skin: Nipple: Areola:
It lies at the level of fourth intercostal space in nulliparous females
Areola:
It is a circular area of skin around the base of the nipple

18. Arterial supply:

19. Posterior intercostal vein Internal thoracic vein
Venous Drainage:
Internal vertebral venous plexus
Azygous vein
Posterior intercostal vein
Axillary vein
Internal thoracic vein
Intracranial saggital & transverse sinus
CIRCULUS VENOSUS
Clavicle and humerus

20. Lymphatic drainage: It consists of two sets:
Those draining the parenchyma of the breast including areola and nipple
Those draining the overlying skin excluding areola and nipple

21. First set:
Those draining the parenchyma of the breast including areola and nipple:
From the parenchyma:
Subareolar plexus of sappey

22. Parasternal lymph nodes
Drainage:
Intercostal nodes
Posterior group
Parasternal lymph nodes
Anterior group
Central group
Apical group

23. Second set:
Those draining the overlying skin excluding areola and nipple
Supraclavicular nodes
Infraclavicular nodes
Parasternal nodes
Axillary nodes
Sub diaphragmatic lymph nodes
Subperitoneal lymph plexus
Krukenberg’s tumour
Hepatic nodes
Drainage

24. Applied anatomy: The breast is the frequent site of carcinoma
Peau d’ orange

25. PECTORAL REGION

26. Muscles of Pectoral Region:
It Includes:
Pectoralis minor
Subclavius
Serratus anterior
Pectoralis major

27. Pectoralis major:
Origin:
Clavicular head
Sternocostal head

28. Insertion:
Lateral lip of intertuberculus sulcus of humerus

29. Nerve supply: Actions: Medial and lateral pectoral nerve
Medial rotation and adduction of the shoulder joint
Clavicular head produces flexion of shoulder joint
Sterno-costal head helps in extension to bring flexed humerus to the side as in climbing

30. Pectoralis minor: Origin: Insertion: Third to fifth ribs
Medial border and upper surface of the coracoid process

31. Nerve supply: Action: Medial and lateral pectoral nerve
Assisted by serratus anterior muscle protracts the scapula
Along with levator scapulae and rhomboideus it depresses the shoulder

32. Subclavius: Origin: Insertion:
Junction of first rib and its costal cartilage
Insertion:
Groove on the undersurface of the middle third of the clavicle

33. Nerve supply: Action: Nerve to subclavius
Stabilise the calvicle during the shoulder movements

34. Clavipectoral fascia
It is a strong sheet of fascia which stretches from the pectoralis minor to clavicle
Structures piercing the fascia:
Cephalic vein
Lymphatics
Lateral pectoral nerve
Thoraco-acromial vessels

35. Serratus anterior: Origin: Insertion:
Eight fleshy digitations from outer surface and upper border of upper eight ribs
Insertion:
Costal surface along the medial border of scapula

36. Nerve supply: Action: Long thoracic nerve
Along with pectoralis minor protracts the scapula
With upper and lower fibers of trapezius it rotates the scapula forward and upwards

37. AXILLA

38. AXILLA /ARMPIT: Situation:
It is a pyramidal shaped space present between upper end of arm and lateral thoracic wall

39. 1 3 5 6 4 2 Boundaries: 1. Apex 2. Base 3.Anterior wall
4. Posterior wall
5. Medial wall
6. Lateral wall 2

40. 1. APEX:
It is also called as cervico-axillary canal

41. 2. Base: Infront : Anterior axillary fold
Behind: Posterior axillary fold

42. 3. Anterior wall

43. 4. Posterior wall

44. 5. Medial wall

45. 6. Lateral wall

46. Contents: Axillary artery and its branches
Axillary vein and its tributaries
Cords of brachial plexus and their branches, long thoracic and intercosto brachial nerve
Axillary lymph nodes
Axilary fat and occasionally axillary tail of the breast

47. Axillary artery:
It is a continuation of third part of subclavian artery at the outer border of first rib

48. Branches:
First part: Superior thoracic artery
Second part:
Thoraco acromial artery
Lateral thoracic artery
Third part:
Subscapuar artery
Anterior circumflex scapular artery
Posterior circumflex artery

52. Quadrangular space

53. Scapular anastomosis:
In each of subscapular, supraspinous and infraspinous fossae
Suprascapular
Deep branch of transverse cervical arteries
With
Circumflex scapular artery

55. Over the Acromion Process:
Acromial branch of Suprascapular artery
Thoraco-acromial artery
With
Posterior circumflex humeral arteries

56. Brachial plexus:
Muscles of upper limb receive innervation from nerves of the brachial plexus
Formation:
Lower four cervical nerves and the first thoracic nerve (C5-8) and T1

58. Parts of Brachial Plexus:
It consists of
R = ROOTS (Ventral rami)
T = TRUNKS
D = DIVISIONS
C = CORDS
B = BRANCHES

60. Roots join to form Trunks! (in neck)
Ventral Rami Trunks C5 C6 C7 C8 T1
Upper trunk
Middle trunk
Lower trunk

61. Trunks Split to form Divisions! (in neck)
Trunks Divisions
Upper
Middle
Lower
Anterior
Posterior
Anterior
Posterior
Anterior
Posterior

62. Divisions Join to form Cords! (in axilla)
Trunks
Divisions
Cords U M L A
LATERAL CORD P A
MEDIAL CORD P A
POSTERIOR CORD P

63. Cords Give off Branches!! (in axilla)
LATERAL PECTORAL NERVE
LATERAL CORD
MUSCULOCUTANEOUS
LATERAL ROOT OF MEDIAN NERVE
MEDIAL PECTORAL NERVE
MEDIAL ROOT OF MEDIAN NERVE
MEDIAL CUTANEOUS NERVE OF ARM
MEDIAL CORD
MEDIAL CUTANEOUS NERVE OF FOREARM
ULNAR NERVE
UPPER SUBSCAPULAR
THORACODORSAL
POSTERIOR CORD
LOWER SUBSCAPULAR
AXILLARY NERVE
RADIAL NERVE

66. APPLIED ANATOMY: 1. ERB’S PARALYSIS:
Site of injury: Upper Trunk of Brachial plexus
Cause of injury: Undue separation of the head from shoulder
Nerves roots involved: C5 – C6
Muscles paralysed:
Biceps, Deltoid, Brachialis & Brachioradialis.
Partly supraspinatus, infraspinatus and supinator

67. Deformity: (Position of the limb) Arm: Adducted and Medially rotated
Forearm: Extended and Pronated
The deformity is known as
Policeman’s tip hand or Porter’s tip paralysis
Disability:
Abduction and lateral rotation of the arm is lost
Flexion and supination of the forearm is lost

68. Site of injury: Lower trunk of brachial plexus
2. Klumke’s Paralysis:
Site of injury: Lower trunk of brachial plexus
Cause of injury: Undue abduction of arm
Nerves roots involved: T1 and partly C8
Muscles paralysed:
Intrinsic muscles of the hand (T1)
Ulnar flexors of the wrist and fingers (C8)
Deformity: (Position of hand)
Claw hand

69. 3.Injury to the nerve to serratus anterior muscle:
Cause:
Sudden pressure on the shoulder from above
Carrying heavy loads on the shoulder
Deformity:
Winging of scapula
Disability:
Loss of pushing and punching movements
Arm cannot be raised beyond 90o